Will Medicare Cover My Implant Surgery (Revision, Removal, or Replacement)?

At Me Clinic, we recognise that implant surgeries—whether for revision, removal, or replacement—are not always cosmetic decisions. For many patients, these procedures address critical medical concerns, from ruptured implants to debilitating complications like capsular contracture.

Understanding whether Medicare can assist in covering the costs of such surgery is vital, and this guide provides all the information you need about eligibility, costs, and the support available at Me Clinic.

Understanding Implant Surgery: Revision, Removal, and Replacement

Implant surgeries fall into several categories, depending on the patient’s needs and medical circumstances:

• Revision Surgery:
  Corrects complications or unsatisfactory results from a previous implant surgery. Examples include resolving asymmetry or issues from capsular contracture.
• Removal Surgery:
  Involves the extraction of implants, either for medical reasons (like rupture or infection) or personal preferences.
• Replacement Surgery:
  Involves removing old or damaged implants and replacing them with new ones, typically required after a rupture or as part of ongoing maintenance.

These procedures can be necessary due to:

• Capsular Contracture:
  Painful tightening of scar tissue around the implant, causing discomfort or distortion of the breast shape.
  
• Ruptured or Leaking Implants:
  Silicone or saline leaks can pose health risks or cause aesthetic changes that require immediate attention.
• Systemic Symptoms:
  Some patients report symptoms like fatigue or joint pain, sometimes linked to Breast Implant Illness (BII).
• Other Complications:
  Chronic infections, persistent pain, or changes in breast shape and position over time.

While some cases are purely aesthetic, many qualify as medically necessary, making them eligible for partial Medicare funding.

Medicare’s Role in Implant Surgery

Medicare provides support for medically necessary procedures, but purely cosmetic surgeries are excluded. Determining whether your surgery qualifies under Medicare depends on several factors:

➔ When Is Implant Surgery Medically Necessary?

Medicare typically supports implant surgeries if they address:

• Health Risks:
  Such as ruptured implants, severe pain, or infections.
• Complications from Previous Surgeries:
  Including capsular contracture, implant displacement, or unsatisfactory outcomes.
• Physical Impairments:
  Chronic pain or physical limitations caused by implants.
• Serious Functional Issues:
  Such as difficulty moving due to complications.

➔ What Does Medicare Cover?

Medicare may cover parts of your procedure under an applicable Medicare Benefits Schedule (MBS) item number. Examples include:

• MBS 45551: For removal of breast prostheses with capsulotomy or capsulectomy.
• MBS 45554: For removal and replacement of breast prostheses.
• MBS 45548: For surgery related to breast deformities or reconstruction.

At Me Clinic, we’ll help you identify whether your condition qualifies for these item numbers and guide you through the Medicare claim process.

➔ Steps to Determine Medicare Eligibility

Securing Medicare coverage for implant surgery involves thorough documentation and a clear medical case. Here’s how Me Clinic can assist:

1. Consultation with a Specialist: Schedule a consultation with one of our experienced surgeons. They will assess your condition and confirm if your procedure meets Medicare’s medical necessity criteria.
2. Documentation of Symptoms: Keep a detailed record of your symptoms, including pain, infections, or physical impairments caused by the implants.
3. Photographic and Medical Evidence: Provide photographs showing the physical effects of the implants and medical records from your GP or specialists outlining the health impacts.
4. Review MBS Item Numbers: Our team will evaluate which item numbers align with your procedure and ensure all requirements are met.

How Me Clinic Supports You

Navigating Medicare can feel overwhelming, but at Me Clinic, we’re here to make the process as straightforward as possible. Here’s how we assist:

➔ Personalised Consultations

Every patient’s situation is unique. Our surgeons provide detailed assessments tailored to your medical history, symptoms, and goals.

➔ Comprehensive Documentation

We help you compile all necessary documentation, including medical reports, referrals, and photographic evidence. This ensures your Medicare claim is robust and compliant.

➔ End-to-End Guidance

From your initial consultation to post-surgery care, Me Clinic provides complete support. We also help coordinate with Medicare and private health insurers to streamline the financial aspects of your care.

Out-of-Pocket Costs: What to Expect

While Medicare can significantly reduce the financial burden of medically necessary implant surgery, it often doesn’t cover all expenses. Here’s a breakdown of potential costs:

➔ Surgeon Fees

Medicare covers a portion of your surgeon’s fees under the MBS item number, but a gap payment may apply.

➔ Hospital Costs

Medicare provides coverage for surgeries performed in public hospitals. If you choose a private facility, you’ll need private health insurance or pay out-of-pocket.

➔ Anaesthesia Costs

These are typically partially covered but may involve some personal expenses.

➔ Post-Surgery Care

Expenses for recovery, such as compression garments or follow-up consultations, may not be included in Medicare coverage.

At Me Clinic, we offer transparent cost breakdowns and help you explore funding options, including private health insurance.

The Benefits of Private Health Insurance

Combining Medicare with private health insurance can significantly reduce your out-of-pocket expenses and provide additional benefits:

• Shorter Waiting Times: Access private hospitals without the delays associated with public healthcare.
• Expanded Coverage: Insurance often covers hospital stays, operating theatre fees, and some aftercare services.
• Shared Costs: Private insurance can help offset costs that Medicare does not fully subsidise.

If you’re unsure how to optimise your Medicare and private health insurance benefits, our team can guide you through the process.

Common Questions About Medicare-Covered Implant Surgery

1. Will Medicare Cover My Entire Procedure?
   Medicare typically covers a portion of the surgeon’s fees for medically necessary procedures, provided they meet MBS criteria. Other expenses, like hospital and anaesthesia costs, may require private health insurance or out-of-pocket payment.
2. What Conditions Are Covered by Medicare?
   Conditions that Medicare may cover include ruptured implants, capsular contracture, severe pain, or complications from previous surgeries.
3. How Do I Begin the Process?
   The first step is booking a consultation with Me Clinic. Our experienced surgeons will assess your condition, confirm medical necessity, and guide you through the Medicare application process.
4. What Sets Me Clinic Apart?
   At Me Clinic, we bring:

• Expertise in Medicare compliance and claims.
• Surgeons with extensive experience in reconstructive and cosmetic procedures.
• A patient-first approach, ensuring you feel supported at every stage.

The Importance of Choosing a Qualified Surgeon

Implant surgeries, especially those addressing medical complications, require skill and precision. When selecting a surgeon, ensure they:

• Are registered with relevant Australian medical boards.
• Have experience in both cosmetic and reconstructive surgeries.
• Adhere to AHPRA guidelines to provide safe, ethical care.

At Me Clinic, our specialised plastic surgeons are highly trained professionals dedicated to your safety and wellbeing.

Final Thoughts

Implant surgeries involving revision, removal, or replacement often go beyond aesthetics, addressing crucial health concerns. Understanding Medicare’s role in covering these procedures can make a significant difference in managing costs.

At Me Clinic, we are committed to helping you navigate the complexities of Medicare eligibility, providing expert care, and supporting you every step of the way. Contact us today to schedule your consultation and take the first step toward better health and peace of mind.

Helpful Resources

For additional details on Medicare and health coverage in Australia, visit:

• Medicare Overview: Australian Institute of Health and Welfare – Medicare Overview
• Private Health Insurance Coverage: Department of Health – What Private Health Insurance Covers
• Private Health Insurance and Medicare: Services Australia – Private Health Insurance and Medicare 

Me Clinic is here to help you achieve your health and wellness goals with confidence and clarity. Reach out today!

Further Reading for Breast Implant Surgery

• Visit Me Clinic’s complete Breast Surgery page
• Visit the Breast Augmentation page
• Visit the Implant Removal page
• Visit the Implant Replacement page.

FAQs

1. Does Medicare cover the removal of breast implants?
   Medicare may cover implant removal if it is medically necessary, such as in cases of rupture, capsular contracture, infection, or severe pain.
2. Will Medicare pay for implant replacement if my implants are damaged?
   If your implants have ruptured or are causing medical complications, Medicare may contribute to the cost under MBS item numbers related to implant revision and replacement.
3. How do I check if my implant surgery qualifies for Medicare coverage?
   A consultation with a specialist surgeon is required to assess your condition and determine if it meets Medicare’s medical necessity criteria.
4. Does private health insurance cover additional costs for implant surgery?
   Private health insurance can help cover hospital fees, anaesthesia, and other costs not fully covered by Medicare, reducing out-of-pocket expenses.
5. What should I do if I need Medicare-covered implant surgery?
   Book a consultation with Me Clinic to evaluate your condition, gather the necessary medical documentation, and navigate the Medicare claim process.